COMPLEMENTARY SELF-CARE STRATEGIES FOR HEALTHY AGING

In Generations: Journal of the American Society on Aging, Fall 1993 Self-care and Older Adults COMPLEMENTARY SELF-CARE STRATEGIES FOR HEALTHY AGING BY SONDRA BARRETT AS the population ages and the healthcare crisis is upon us, prevention and self-care practices throughout our life span make both fiscal and physical sense. Chronic illnesses such as those frequently seen in older people - arthritis, hypertension, cancer, asthma, chronic pain - are costly, and symptoms are not eradicated by conventional biomedicine (Ingelfinger 1977; Bailar and Smith, 1986). Common chronic medical problems in older people may be more effectively treated by a new collaboration among the primary healthcare provider/physician, the specialist(s) of complementary care, and the patient. In addition, because of the frustration with conventional medical practices, many individuals are choosing to take more personal responsibility for their health by exploring a variety of selfregulatory, mind/body, and wellness practices, independent of the physician's input. These practices can be either conventional (such as behavior modification for smoking cessation or weight loss, exercise, rehabilitation groups, risk factor reduction) or "alternative" by today s healthcare standards (e.g. acupuncture, meditation, nutritional counseling, massage). Furthermore, evidence is accumulating that attitudes, stress, feelings of hopelessness, anger, and loss of control all influence our health, our behaviors, and our ability to cope with illness and the frailties of aging. Complementary or alternative care refers to those practices that often come from older, cross-cultural perspectives of health and healing, and that often focus on lifestyle reevaluation and the mind/body interaction. By their very nature, they are preventive in intention. This article will focus on complementary or alternative self-care both in terms of collaboration with the primary care physician and individual exploration of self-care practices. Definition of these terms is first necessary to create a common language for examining the controversial and often misunderstood options of "alternative health/ self-care. The move to self-care in this country implies a growing need for the individual to be seen as a whole and part of a greater environmental and social system. An astute and sensitive health practitioner can help in guiding choices for self-care practices and in setting goals with the individual desiring to take greater responsibility for his or her health. Inherent in the concept of alternative care are notions of personal responsibility and self-care, both of which are implied by the individual actively seeking other ways for heating. The introduction at the National Institutes of Health of the new Office of Alternative Medicine (OAM), the very successful Bill Moyer's PBS TV series and national best-selling book Healing and the Mind, and a recent article in the New England Journal of Medicine attest to the growing interest in therapies and practices not typically provided by the medical community (Eisenberg et al., 1993). For consistency; this article will use Eisenberg's definition of "unconventional" as those medical practices not commonly taught at medical schools or available at hospitals in the United States." Since "unconventional," alternative, and "unorthodox are pejorative terms, the more positive word "complementary;" as used in the United Kingdom, is preferred. In the United Kingdom, the aim of complementary medicine is to broaden medical alternatives by viewing long-standing therapies like acupuncture, osteopathy, and homeopathy not as alternatives to orthodox medicine but as therapies to work alongside it. A brief description of these practices will suffice to suggest how they may be used to augment or expand conventional medical care. Complementary practices include Chinese medicine, acupuncture, acupressure, Ayurvedic medicine, yoga, homeopathy, herbal medicine, osteopathy, chiropractic, massage therapy, cxercisc, martial arts, relaxation techniques, imagery, lifestyle and dietary change, biofeedback, hypnosis, traditional Native American medicine, spiritual healing, and self-help groups. The common thread linking many of these is a view of the body and health that is radically different from that of the present Western medical paradigm. This view is expressed in the term 'holism," in which the health of the whole individual is considered in a context that brings together body, mind, and spirit. Many of these other views and practices of healing are "energy-based" in contrast to the matter-based" medicine of the West. The new quantum Einsteinian physics hypothesizes that matter is energy and provides a scientific framework for a strategy of medicine that includes healing the energy of' the system as well as the physical Barrett FALL 1993 J. American Society of Aging 49

structure. The philosophical ground of Chinese medicine and many other complementary practices is that disease is caused by a disharmony or imbalance of energy flow in the body. Bringing energy into balance or increasing it is one goal of these self-care and medical practices. Even though the Western medical model does not yet include the concept of energy in its philosophy, simply practicing a breathing exercise or engaging in self-massage may provide a physical experience of the flowing of energy or warmth; perhaps that is enough evidence to convince people to adopt a complementary practice, one that complements life. Traditional Chinese medicine, at least 5,000 years old, combines acupuncture, acupressure, exercise, and herbal treatment with education about healthy diet and nourishment of the body, mind, and spirit. Guided by a trained practitioner, these practices are seen as preventive, life-long investments in one s quality of life. It is based on a concept of energies, yin and yang, which teaches that these opposite and complementary forces are part of all life, inside us and outside. This energy or vital force, called Qi or Xi (pronounced chee), circulates through channels or meridians among the organs within the body. An adequate amount of Qi must be present and able to flow freely for health. The Chinese Taoist view of health is that there is an interrelationship between our sources and uses of energy, our diet, expression of our emotions, and the connection we have with our environment, the seasons, and nature. Illness occurs when these energies are out of balance. Chinese medicine aims at restoring the balance. The basis of acupuncture is to promote the free flow of Qi in thc meridians by inserting extremely fine needles at specific points along these meridians..acupressure, a valuable self-care technique, does a similar thing without insertion of a needle: The fingers exert pressure or force on the points. When the energies are rebalanced, symptoms are relieved. Furthermore, acupuncture and acupressure have a profound relaxing effect, and Western scientific research has shown that endorphins. the body's own morphine molecules, are released when certain acupuncture points are stimulated. In China, acupuncture sometimes replaces anesthesia during surgery. Chinese medicine can be used both for symptom removal and improving overall health through strengthening the energy flow of the body. An ancient physical form of Chinese medicine that is becoming recognized in the West for its health values is Qi Gong, a series of exercises that help integrate breath and body. No one is too old to learn these gentle movements; in China, 8oand 90-year-oIds can be seen performing them. These exercises also include self-massage to be used before getting out of bed in the morning or by the bedridden. Since unconventional, 'alternative,' and unorthodox' are pejorative terms, the more positive word complementary' is preferred. Ayurvedic medicine, whose philosophy is similar to the energy-based philosophy of Chinese medicine, originated in India and uses a system of herbs, diet, massage, exercise, and energy balance. Yoga, also originating in India, comprises a system that in this country emphasizes various physical postures and breathing techniques designed to promote flexibility of the tissues, relaxation, and integration of body and mind. Homeopathy is based on a specific method of prescribing and preparing medicines, most of which are herbal in origin. Homeopathic remedies stimulate the body's own energies so that symptoms are eliminated through strengthening the vitality of the body. It is an energy-based medicine system founded on the principle that "like cures like" This principle of "similars" is not unknown to conventional medicine, where it underlies vaccination and allergy desensitization. However, homeopathy departs from the conventional pharmaceutical approach in that homeopathic remedies are said to retain their potency in very dilute preparations. Some remedies are diluted to a point where there cannot be one single molecule of the original substance left, yet it is thought that the vibrational pattern" of the material is still present. The British National Health Service includes several homeopathic hospitals arid physicians who practice homeopathy. In practice, a homeopath will take a very extensive history of the person, often many hours long delving into his or her emotional, spiritual, and physical behaviors and symptoms. A homeopath treats the symptom con-figuration rather than a disease. Osteopathy and chiropractic are primarily body-based modalities that emphasize physical manipulation and alignment of the body, particularly the spinal column Both use a hands-on approach, may incorporate massage, and Barrett FALL 1993 J. American Society of Aging 50

are frequently applied for chronic back pain and other neuromusculoskeletal problems (Kaptchuk and Croucher, 1986). However, an osteopath is a fully licensed physician who uses physical manipulation as an adjunct to other standard medical practices. Understanding these different ways of looking at health and healing in the elderly may assist the older client to choose appropriate care - care that addresses the more holistic view of body, mind, and spiritual issues and helps create a greater sense of control so important to healthy aging, (Rodin, 1986). The argument in conventional medicine against the validity and efficacy of any of these therapies lies in the lack of Western research data. Now with the introduction of the OAM, funds will presumably be available for investigating them. However, even areas as well researched in West medicine as is nutrition ace still considered secondary to conventional drug therapy. Eisenberg and colleagues (1993) found that 30 percent of the 1.500 adults questioned who used complementary therapies were over 50 years of age and sought them more frequently for chronic rather than life-threatening medical conditions. However, they were also used for health promotion and disease prevention. Typically, many did this without the supervision or knowledge of their physician or other healthcare provider. Since many complementary practices may influence the clinical course of an illness or the need or dosage of medication, open. nonjudgmental communication is essential between patient and primary care provider about self'-care modalities used. Patients often fear to let their physicians know that they are using other healing techniques because of the possible condemnation of their choices, the physician's potential bias toward considering them quackery, and the belief that their provider may be uninformed about these other treatments. A dialogue needs to begin between patient and physician as to the full scope of the person's health behaviors arid attitudes with an open mind and respect for the healing potential of power of belief, the following questions might be asked to enhance communication and ensure better care: 1. Are you going to any other health practitioners, such as an acupuncturist or homeopath? How often? What herbs or remedies are you taking? (Many Chinese herbs like ephedra - which contains epinephrine, a stimulant- are powerful in their actions and duplicate some hormonal responses. Western scientific knowledge may help us appreciate the possible effects that these herbs can produce. Acupuncture may necessitate reducing the amount of pain-killers you are taking, since endorphins, the body's endogenous morphine, are released.) 2. Are you practicing any kind of meditation or relaxation technique? If so, what kind? How often? (Both of us might benefit if you show me how it is done. This, too, may change the quantity of medication you are taking.) 3. What is your diet like? Are you a vegetarian? If so, arc you getting adequate sources of vitamin B12? What is your intake of fat and sodium? Understanding these different ways of looking at health and healing in the elderly may assist the older client to choose appropriate care. 4. Are you taking any nutritional supplements, vitamins and minerals? Which ones, and how much? From the disease model perspective, several areas of complementary self-care have been documented as being effective for reversing coronary artery disease and hypertension, the number one cause of death in the older population (Scherwitz, Graham arid Ornish, 1985; Ornish, 1991; Benson, Greenwood and Klemchuk, 1975). Research, spearheaded first by the research cardiologists Herbert Benson, in the seventies, and Dean Ornish, in the eighties, demonstrated the value of incorporating Asian healing techniques into Western medical practice. Benson discovered the relaxation response. The body's calming physiological reactions that counteract stress, the fight or flight response of the autonomic nervous system, Physiologically, the relaxation response induces slower and deeper Barrett FALL 1993 J. American Society of Aging 51

breathing, lowers heart rate and blood pressure. and lessens muscle tension (Wallace and Benson 1972). Benson's relaxation response, a simple breathing and mental focusing exercise, is easily learned in classes or taught by the physician or other health educator. Based on the ancient practice of meditation, this integrated physiologic response is an effective way to improve coping with stress, to lower high blood pressure, decrease the level of chronic pain, and diminish nausea of cancer chemotherapy. It may also moderate anxiety and negative coping strategies like drug and food abuse. When used daily, it can bring moments of rest and rejuvenation to an otherwise hectic or stressful day. The relaxation response, which can be elicited by a variety o self-care techniques that affect the body and mind, include the following: autogenic training, progressive relaxation, hypnosis, and yoga. transcendental meditation, Zen meditation, mindfulness meditation, imagery, self-hypnosis, breath work, and biofeedback. These can be taught by the primary caregiver or an alternative provider; many can be self-taught. Other health benefits are derived from inducing relaxation: It helps the individual cope better with medical treatment; it gives the individual a sense of control over his or her health or response to life changes; and it improves immune functions (Glaser, 1987). As with most self-care practices, building a relaxation routine into a daily experience may augment the individual's sense of worth, control, and inner peace. The National Institutes of Health now recommends a meditation/relaxation practice as one of the first attempts to moderate mild hypertension. Whereas Benson brought the practice of meditation and relaxation to Western medicine, opening the door to understanding the physiological processes, Ornish took meditation with heart patients one step further and added other stress-reduction techniques, group support, and a low-fat vegetarian diet to reverse the progression of coronary blockage (Ornish et al., 1990). Without using cholesterol-lowering drugs or surgery, coronary artery disease could be reversed by engaging in these rigorous self-care practices. Ornish's program, built from his own personal experience with these complementary practices, includes ongoing group support throughout the process of making these changes in one s life. The four components of this physician-guided self-care program are dietary changes to less than 10 percent fat, moderate aerobic exercise (daily walks for a half-hour or one-hour walks three times a week), stress management every day for one hour, and group support twice weekly. Changing lifestyle, although not an easy task, can be done without the costs, risks, or side effects of the conventional medical practices now available and can be built on this model. The stress management techniques used by Ornish are fundamental to many of the self-care practices for encouraging healthy aging. These include stretching exercises grounded in ancient yoga, harnessing the imagination in imagery for healing, meditation, and breathing exercises. Originally, many of these practices were used in the United States in the space program, then were used to alleviate physical symptoms of illness - often the incentive for people to start engaging in them. However, in the East they were primarily developed as tools for spiritual transformation. More consistent, long-term practice of these stress-reducing exercises may, in fact, help promote spiritual health here as well. Since one view of modern illness is that it is rooted in chronic stress and social isolation, long-term practice of some of these simple interventions may support an individual in becoming more spiritually and emotionally connected, an essential for healthy aging, living, and dying. Many of the self-care practices used in these programs for treatment of heart disease or other chronic illnesses come from the Asian systems of medicine. These longevity practices, which include nutritional advice, lifestyle prescriptions, physical exercises, as well as therapeutic practices have stood the test of time, having been used for hundreds if not thousands of years in China, Tibet, and India. When examining complementary healthcare arid self-care practices, we should look at the Western biomedical model that they may fit into, the new field of psychoneuroimmunology This multidisciplinary approach to health examines the ways in which stress, mind, attitudes, relationships, and other factors influence health and recovery from illness. Implicit in healing and making lifestyle choices is the influence of a person's attitudes, beliefs, values, support system, and environment. This field is beginning to generate data that provide the rationale for the practice of some of these self-care techniques, especially relaxation and group support (KiecoltGlaser et al., 1985; Spiegel et al., 1989). Evidence suggests that stress impairs the immune response, which is protecting against cancer, infections, and autoimmune diseases. The incidence of these illnesses increases as we age. Engaging in some form of stress reduction may be pro- tective (Locke, 1986) and may enhance our sense of control even when confronted by physical limitations. Many of these complementary practices, when done consistently, become lifeaffirming and empowering, no matter what the state of health. Older people are frequently undergoing life changes that make them more vulnerable to the effects of uncontrollable stress-immune system depression, psychological depression, and increase in chronic illness. Stress-reduction and self-care strategies provide opportunities for choice and control that have positive effects on the health and well-being of older people. Barrett FALL 1993 J. American Society of Aging 52

My experience in teaching many of these practices has shown that it is important - and often more individually fulfilling to learn in a group setting. The group provides support in making these changes and a framework for decreasing the sense of isolation by creating social connections with others who are attempting the same or similar life changes. Once the practices are established as viable, health-promoting, and enjoyable, they become truly self-care. Sondra Barrett Ph.D. is a consultant in psychoneuroimmunology, complementary healthcare, and education; associate professor of lntegral Health, California Institute of Integral Studies, San Francisco; president of Health Education Resource Services. She also maintains a private clinical practice in Larkspur, Calif. REFERENCES Bailar, J. C. and Smith, E. M., 1986. Progress Against Cancer? New England Journal of Medicine 314(19):1226-32. Benson, H.,Greenwood, M and Klemchuk, H., 1975. "The Relaxation Response: Psychophysiological Aspects and Clinical Applications." Psychiatry in Medicine 6(i): 36-42. Eisenberg,D. M. et al, 1993. Unconventional Medicine in the United States. New England Journal of Medicine 328(4):2463-52. Glaser,R et al., 1987. Stress-related Immune Suppression: Health Implications. Brain, Behavior, and Immunity I: 7-10. Ingelfinger, F J., 1977. Health: A Matter of Statistics or Feeling? New England Journal of Medicine 296(8): 448-49. Kaptchuk, T and Croucher, M., 1986. The Healing Arts. London: British Broadcasting Company. Kiecolt-Glaser,J. et al., 1985. "Psychosocial Enhancement of Immune Competence in a Geriatric Population." Health Psychology 4:25-41. Locke, S. K, 1986. Psychological and Behavioral Therapies for Disorders Associated with the Immune System New York Institute for the Advancement of Health. Ornish D, 1991. "Reversing Heart Disease through Diet, Exercise and Stress Management." Journal of the American Dietetic Association 91: 162-65. Ornish, D. et 31., 1990. "Can Lifestyle Changes Reverse Coronary Atherosclerosis? The Lifestyle Heart Trial." Lancet 2(8708):129~33. Rodin, 1.1986. Aging and Health: Effects of the Sense of Control." Science 233:1271-76. Scherwitz, L, Graham, L. E. and Ornish, D. M., 1985," Self-involvement and the Risk Factors for Coronary Heart Disease." Advances 8(2): 6-18. Spiegel, D. et al., 1989. Effect of Psychosocial Intervention and Survival Time of Patients with Metastatic Breast Cancer." Lancet 2(8677)1487-91. Wallace, R. K and Benson, H., 1972. "The Physiology of Meditation." Scientific American 226:85-90. Barrett FALL 1993 J. American Society of Aging 53